If You Drive, I’ll Pay for Gas: Critical Developments in Ownership and Financing of the National HIV/AIDS Response

While taking a stroll though the newspaper headlines on allAfrica.com, I was struck by a story from Uganda which provides a real world illustration to ground some of the discussions at the International AIDS Society Conference that just happened in South Africa and the AIDS Implementers’ Meeting in Namibia last month. Apparently many bi-lateral and multi-lateral donor-funded ART providers in Uganda have announced they are scaling back ART services (funding scale backs have also been announced in Tanzania). Many examples are given including a PEPFAR supported antiretroviral therapy clinic in Masindi Hospital – which is run by one doctor and a number of volunteers - that had enrolled over 2000 patients (with around 500 currently on ARVs). The article quotes Dr Michael Strong, the PEPFAR coordinator, describing problems with the supplies of ARVs in the national programme.

‘We expect that PEPFAR funding for Uganda will continue at its current level of around $280m annually through 2013. But this will still leave a gap between national treatment needs and the funds available. Uganda needs to identify other resources to fill this gap.’

Strong went on to say that PEPFAR will institute a blanket freeze on new patient enrolment at this time.I’m not sure where Dr. Strong hopes Ugandans will get this money, considering that developing countries are expected to be hit harder by the current crisis than the developed economies that are scaling back funding. This article is particularly troubling because the global health community, and PEPFAR in particular, claims so much success at putting people on treatment. A few question for posterity: has the global HIV/AIDS response in Uganda just peaked? Or is this pull-back a temporary blip? Should we now lower our expectations?At last week’s IAS conference in Cape Town, Dr. Eric Goosby laid out a vision for PEPFAR under the new administration (watch the video here), much of it inspiring, but with one red flag: PEPFAR’s plan to begin transferring responsibility for financing for HIV/AIDS programs to recipient countries (see the recent blog post on Partnership Frameworks from Nandini Oomman). Admittedly, he said this was a long term vision, and something we had to keep on the horizon to ensure a sustainable country-driven response. However, as far as paths to ‘sustainability’ go, there is an important difference between developing the capacity for effective and ongoing programs and simply asking countries to start picking up the bill for PEPFAR programs as an exit strategy.It is premature to discuss PEPFAR’s timetable for financial withdrawal when incidence is still very high, treatment programs are turning away patients, and national health systems remain in no position to take on the massive, often parallel HIV/AIDS programs that have been erected in the past six years. The AIDS response in developing countries is still an expensive work-in-progress, complicated by the fact that PEPFAR has in the past set its own course, with global targets and policies mandated by the US Congress planned on a yearly basis.We at the HIV/AIDS Monitor are proponents of PEPFAR moving from an emergency response to become part of a long-term sustainable development response designed by stakeholders in countries. However, there is a long way to go to get there from here. The way forward should be to have country driven strategies supported by expanded global financing, rather than handing over the wheel after the car is out of gas. Let’s hope that the recent news from Uganda and Tanzania is not foreshadowing another lesson in donor fatigue and the limits of externally mandated project-based approaches to development.